Bloody tears: Evert before you investigate – A photo essay

A 17-year-old female presented with complaints of blood in her tears from the left eye (OS) for 2 months. Symptoms were aggravated by eye rubbing. She was not on any medications. There was history of chalazion excision done 2 years ago in OS. There was no history of bleeding diathesis or vicarious menstruation. She had consulted elsewhere and underwent syringing of the lacrimal sac and blood investigations for hematological disorders, which were all unremarkable. Magnetic resonance imaging of the orbit and sinuses had also been advised. She had come to us for a second opinion. On examination, she was emmetropic. On eversion of the left upper lid, a blood-filled pedunculated lesion was seen [Fig. 1]. Examination of puncta, lacrimal gland and sac, anterior nares was normal. A diagnosis of pyogenic granuloma was made and confirmed on histopathology following excision biopsy with cautery [Fig. 2]. The patient is under regular follow up. Discussion: Hemolacria or blood in tears can be a daunting disease to treat as the etiologies are multiple and include various sight-threatening and life-threatening diseases[1] such as malignancies of the lacrimal gland, sac, and conjunctiva and hematological disorders. Infectious[2] causes include canaliculitis (Actinomyces israelii), tuberculosis, or rhinosporidiosis of the sinuses or lacrimal sac; HPV-associated papilloma of the lacrimal sac; and inflammatory[3] lesions such as papillary conjunctivitis, erythema multiforme, and pyogenic granuloma. Pyogenic granuloma is a benign vascular proliferation. The term is a misnomer as it is neither purulent nor granulomatous. It is postulated to be due to trauma-induced antigenic dysregulation.[4] It has a tendency to bleed after trivial trauma, with eventual fibrosis and involution. Management options[5] include surgical excision with cautery, curettage, or laser. Non-surgical options include topical steroids, cryo, laser ablation, radiation, bleomycin injection, etc., Conclusion: Pyogenic granuloma of the conjunctiva can present as hemolacria. Careful ocular examination including lid eversion is mandatory in evaluating and treating hemolacria.Figure 1: A 1 mm × 0.5 mm × 0.3 mm vascular pedunculated cystic lesion filled with blood seen in the lateral third of the upper tarsal conjunctiva. A single hair follicle seen protruding from the lesionFigure 2: Slit-lamp image of the left eye 1 week after excision biopsyFinancial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.